Racial, Ethnic, and Geographic Disparities in Rates of Knee Arthroplasty
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《新英格兰医药杂志》
To the Editor: Skinner et al. (Oct. 2 issue)1 report that the rates of total knee arthroplasty in Manhattan are significantly greater among Hispanic women than among non-Hispanic white women. These data corroborate those we have reported for New York City2 and have confirmed for California (unpublished data). However, we urge caution in the use of Medicare data to assess or define disparities in the rates of total knee arthroplasty or total hip arthroplasty. In New York City, the age distributions among patients who undergo these procedures differ significantly according to race and ethnic group (Table 1). We found the same trend when using California and National Hospital Discharge Survey data (unpublished data). Many Hispanics and blacks undergo arthroplasty before the age of 65 years, at a mean age that is 3 to 13 years younger than that of whites. In addition, we found that many arthroplasties performed in Hispanics and blacks 65 years of age or older are not billed to Medicare. Thus, reliance on Medicare data does not accurately reflect the number of arthroplasties actually performed. Although it is extremely important to address disparities in health care delivery to racial and ethnic minority populations, Medicare data may not be helpful in measuring the magnitudes of disparity.
Table 1. Age Distribution of Non-Hispanic Whites, Hispanics, and Blacks Undergoing Total Knee or Total Hip Arthroplasty, According to 2001 Statewide Health Planning and Research Cooperative Inpatient Discharge Data for New York City.
Kimary Kulig, Ph.D.
Clifton O. Bingham III, M.D.
Hospital for Joint Diseases
New York, NY 10003
kk477@columbia.edu
Larry L. Steele, Ph.D.
New York State Department of Health
Albany, NY 12237
References
Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med 2003;349:1350-1359.
Kulig K, Steele LL. Are racial and ethnic minorities more likely to undergo total knee replacement? Arthritis Rheum 2002;46:Suppl:S610-S610. abstract.
The authors reply: Kulig and colleagues suggest that our estimates of racial disparities in the Medicare population are exaggerated because of a timing effect according to which minority groups undergo surgery at younger ages than other populations of patients, leading to lower apparent surgical rates among Medicare recipients. But why are median ages at which total knee arthroplasty is performed in minority groups so low? A likely reason is that black and Hispanic populations are younger than other populations. In 2001, the ratio of the number of persons 65 years of age or older to those 45 to 64 years of age was 0.60 for non-Hispanic whites, 0.42 for blacks, and 0.35 for Hispanics.1 Even if age-specific rates of surgery were identical according to race or ethnic group, the fact that a population is younger would suggest that the median age at which surgery is performed in that population is lower.
Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for 2001 point to the presence of disparities in the population under the age of 65 years as well. Crude surgical rates (the total number of knee arthroplasties performed among persons less than 65 years old divided by the total number of persons 35 to 64 years old) are 0.8 per 1000 for non-Hispanic whites, 0.6 per 1000 for blacks, and 0.4 per 1000 for Hispanics (McKnight R: personal communication). Although we do not find evidence in support of the timing hypothesis, we do recognize the need for more research on disparities in the use of total knee arthroplasty in younger populations.
Jonathan Skinner, Ph.D.
Dartmouth College
Hanover, NH 03755
James Weinstein, D.O.
Dartmouth Medical School
Lebanon, NH 03756
james.weinstein@dartmouth.edu
Table 1. Age Distribution of Non-Hispanic Whites, Hispanics, and Blacks Undergoing Total Knee or Total Hip Arthroplasty, According to 2001 Statewide Health Planning and Research Cooperative Inpatient Discharge Data for New York City.
Kimary Kulig, Ph.D.
Clifton O. Bingham III, M.D.
Hospital for Joint Diseases
New York, NY 10003
kk477@columbia.edu
Larry L. Steele, Ph.D.
New York State Department of Health
Albany, NY 12237
References
Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med 2003;349:1350-1359.
Kulig K, Steele LL. Are racial and ethnic minorities more likely to undergo total knee replacement? Arthritis Rheum 2002;46:Suppl:S610-S610. abstract.
The authors reply: Kulig and colleagues suggest that our estimates of racial disparities in the Medicare population are exaggerated because of a timing effect according to which minority groups undergo surgery at younger ages than other populations of patients, leading to lower apparent surgical rates among Medicare recipients. But why are median ages at which total knee arthroplasty is performed in minority groups so low? A likely reason is that black and Hispanic populations are younger than other populations. In 2001, the ratio of the number of persons 65 years of age or older to those 45 to 64 years of age was 0.60 for non-Hispanic whites, 0.42 for blacks, and 0.35 for Hispanics.1 Even if age-specific rates of surgery were identical according to race or ethnic group, the fact that a population is younger would suggest that the median age at which surgery is performed in that population is lower.
Data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for 2001 point to the presence of disparities in the population under the age of 65 years as well. Crude surgical rates (the total number of knee arthroplasties performed among persons less than 65 years old divided by the total number of persons 35 to 64 years old) are 0.8 per 1000 for non-Hispanic whites, 0.6 per 1000 for blacks, and 0.4 per 1000 for Hispanics (McKnight R: personal communication). Although we do not find evidence in support of the timing hypothesis, we do recognize the need for more research on disparities in the use of total knee arthroplasty in younger populations.
Jonathan Skinner, Ph.D.
Dartmouth College
Hanover, NH 03755
James Weinstein, D.O.
Dartmouth Medical School
Lebanon, NH 03756
james.weinstein@dartmouth.edu